Intramedullary nailing versus external fixation in Gustilo type III open tibial shaft fractures: a meta-analysis of randomised controlled trials.

Open tibial shaft fractures are the most common of long-bone open fractures. Management of the fracture is either by intramedullary nailing (IMN) or by external fixation (EF). Since the literature does not indicate clearly which is more effective, a meta-analysis was conducted to establish which approach is more suitable to treat Gustilo type III fractures. MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE and CINAHL databases were searched for randomised controlled trials (RCT) describing IMN and EF treatment of Gustilo type III fractures. As of 15 November 2012, five RCT involving 239 patients had been published; the outcomes examined in this study are their surgical complications. Data analysis led complications to be grouped into infection, fracture healing problems (non-union, malunion) and "other complications" (vascular injury, revision surgery, soft tissue damage, mechanical failure and tibial malalignment). IMN was associated with lower rates of infection and fracture healing problems; the differences between the two approaches for "other complications" were not significant. The data indicate that IMN is the treatment of choice for Gustilo type III fractures.

Treatment of pseudoarthrosis after minimally invasive hallux valgus correction.

OBJECTIVE: Treatment of mild and moderate hallux valgus deformities. DISCUSSION: Minimally invasive technique enables surgeons to treat mild and moderate hallux valgus deformities with excellent and good results in the majority of patients. Nonunion of first metatarsal, moreover, has only rarely been reported. SUMMARY: We describe the essential steps of a surgical technique for the treatment of nonunions after miniinvasive subcapital first metatarsal osteotomy reconstructed using a tricortical iliac crest bone graft.

Chopart arthrodesis with graft bone from the iliac crest after a traumatic subamputation of the forefoot: surgical technique.

We present a 49-year-old man with a traumatic subamputation of the forefoot, associated with lacerated wound in correspondence of the dorsal surface of the right foot, with injuries of tendinous, ligamentous and vascular structures and with the loss of talus head. The patient underwent salvage arthrodesis of the talonavicular and calcanealcuboid joints with graft bone harvested from the iliac crest. The patient was re-evaluated during a clinical and radiographic follow-up. The arthrodesis was consolidated in ∼3 months. There were no infectious problems and the patient has resumed normal work activities. At a sixth month follow-up, the patient had returned to work and remained pain free while walking. Early anatomic reduction, stable fixation and ligament reconstruction are essential for a good outcome. Primary arthrodesis is a viable option for severe midfoot fracture dislocations, because it facilitates rehabilitation and functional recovery and obviates the need for a secondary arthrodesis should arthritis arise.

Operative delay and mortality in elderly patients with hip fracture: an observational study.

BACKGROUND: Hip fracture is the third cause of death among the elderly and appears to be increasingly frequent. We analysed the influence of the major variables in hip fracture management in relation to 30-day mortality. MATERIALS AND METHODS: The records of all patients with isolated hip fracture treated at a regional trauma centre from January 1995 to September 2008 were reviewed. Data on demographics, comorbidities, operative delay, complications, functional status at discharge and mortality were collected and subjected to univariate and multivariate analysis. RESULTS: The cohort included 1,199 patients; the mortality rate was 11.7%. Surgery was performed within 48 h of injury in 17.7% and after more than 48 h in 82.3%; the mortality rate was 9.27% in the former and 10.4% in the latter patients; however, at variance with previous reports, operative delay was not associated with a worse outcome in patients with comorbidities. CONCLUSIONS: Our data support the policy envisaging fracture repair within 48 h in stable patients and delayed surgery (>48 h) in those with comorbidity conditions requiring stabilization.

Treatment of osteoid osteoma with CT-guided percutaneous radiofrequency thermoablation.

Osteoid osteoma is a benign bone tumor with a male predominance occurring mainly in children and young adults. The most common symptom is intermittent pain that worsens at night and is at least partially relieved by nonsteroidal anti-inflammatory drugs. The purpose of this study was to assess the long-term effectiveness of computed tomography-guided percutaneous radiofrequency thermoablation in patients with a minimum follow-up of 2 years. Twenty patients with osteoid osteoma (15 men and 5 women) with a mean age of 20.7 years (range, 4-61 years; 12 patients aged 20 years or younger) underwent computed tomography-guided percutaneous radiofrequency thermoablation. Lesion sites were the femur (n=9), tibia (n=7), pelvis (n=1), talus (n=1), cuneiform bone (n=1), and humerus (n=1). Mean follow-up was 44 months (range, 3-106 months). Pain relief was significant in 95% of patients; it disappeared within 24 hours in 14 patients, within 3 days in 4, and within 7 days in 1. The patient with persistent symptoms underwent another percutaneous radiofrequency thermoablation procedure that was successful. The difference between pre- and postoperative pain was significant (P ≤ .01). No recurrences occurred. Computed tomography-guided percutaneous radiofrequency thermoablation is a safe, minimally invasive, and economical procedure with high technical and clinical success rates, and it effectively and durably enhances quality of life.

Hospital cost of treating early dislocation following hip arthroplasty.

Dislocation is a frequent and costly complication of hip arthroplasty. The purpose of this study was to assess the financial impact on the treating institution of this complication in patients with primary hemiarthroplasty (HA), total hip arthroplasty (THA) and revision surgery (RTHA). Between October 2001 and August 2009, 2014 consecutive hip arthroplasties were performed at our institution, of which 87 (18 HA, 44 THA and 25 RTHA) dislocated within 6 weeks of the primary operation. The average cost of treating implant dislocation by closed reduction, open reduction or revision was assessed and expressed as a percentage cost increase compared to an uncomplicated procedure. Of the 87 dislocated implants all needed one or more closed reductions and 52 eventually required revision surgery. An early dislocation increased the cost of HA, THA and RTHA by 472%, 342% and 352%, respectively.

The external rotation method for reduction of acute anterior shoulder dislocations.

BACKGROUND: Shoulder dislocations account for almost 50% of all joint dislocations, and are most commonly anterior (90-98%) and occur due to trauma. This prospective study was conducted to report our experiences of using the external rotation method (ERM) in the reduction of acute anterior shoulder dislocation. MATERIALS AND METHODS: Between August 2006 and April 2007, ERM was applied to 31 patients who presented with traumatic anterior shoulder dislocation to the Emergency Department of our Hospital which is a level 2 trauma centre. We evaluated the type of dislocation, the effectiveness of the procedure in achieving reduction, the need for premedication, the ease of performing the reduction, and complications, if any. RESULTS: Of the 31 patients, 29 had a successful reduction. No premedication was required in 25 patients who had a successful reduction, and the average time required for reduction in 25 was less than 2 min. Only five patients reported severe pain during the process of reduction. The method was not successful in two patients in whom the reduction was achieved under narcosis. We experienced a success rate of 89% at the first attempt. None of the patients encountered any complication. CONCLUSIONS: ERM for the reduction of acute anterior dislocation of the shoulder is a safe and reliable method, mainly without requirement for any sedatives or opiate analgesics, that can be performed relatively painlessly for anterior shoulder dislocations. As no single method has a 100% success rate, ERM is a useful one to know.

Irreducible isolated subtalar dislocation: a case report.

Subtalar dislocations are uncommon and account for approximately 1% of all dislocations. Optimal management is by immediate closed reduction under general anesthesia. We report 3 cases of irreducible, isolated subtalar dislocation that required an open procedure. Closed reduction failed in 2 patients with lateral dislocation due to interposition of the posterior tibialis tendon caused by a large tear of the flexor retinaculum. The flexor retinaculum was accurately reconstructed after the reduction. In the third case, a medial dislocation, a displaced extensor retinaculum prevented relocation of the talar head and required resection. We also discuss the mechanisms for irreducible subtalar dislocations.

Ubiquitin ligases MuRF1 and MAFbx in human skeletal muscle atrophy.

INTRODUCTION: Several pathological conditions can induce skeletal muscle atrophy and seem to share common enzyme pathways. In catabolic states where proteolysis is increased, two genes specific to muscle atrophy, MuRf1 and MAFbx, are upregulated. These encode ubiquitin ligases, which bind to and mediate ubiquitination of myofibrillar proteins for subsequent degradation during muscle atrophy. METHODS: Fifteen patients undergoing leg amputation were divided into two groups. Group A included 12 elderly patients (mean age 79years) amputated for vascular disease (complicated by diabetes in four), chronic osteomyelitis or squamous cell carcinoma. Group B included three car accident victims (mean age 32years) amputated due to acute arterial insufficiency. Gastrocnemius muscle biopsies were collected for a histochemical and immunohistochemical (anti-MuRf1, anti-MAFbx) study. RESULTS: Group A specimens showed a decreased cross-sectional fiber area and length, adipose tissue replacement, and MuRf1 and MAFbx immunoreactivity. Muscle cells showed MuRf1 and MAFbx subsarcolemmal immunoreactivity and weak extracellular matrix immunoreactivity. Group B samples exhibited mild muscle structural changes; they did not stain with anti-MuRf1 or anti-MAFbx, and neither did sections showing muscle degeneration and adipose tissue replacement. DISCUSSION: Results of our preliminary study showed upregulation of MuRf1 and MAFbx in atrophied muscle and support their role as regulatory peptides in various conditions that lead to muscle atrophy. Data suggest that the study of cellular pathways can help identify promising targets for effective new treatments for skeletal muscle atrophy. CONCLUSION: The treatment of several orthopedic conditions is complicated by muscle atrophy; potential treatments could be directed to specific sites where these proteins are localized.

A rare European case of Madura Foot due to actinomycetes.

We present a case of mycetoma by Actinomadura spp. on the foot of an Albanian young man arrived to our observation approximately 5 years after the first clinical manifestations (hard tumefaction, slightly painful upon weight-bearing and palpation and cutaneous fistulas that discharged an abundant granulomatous secretion). Direct microscopic analysis and culture of the white-yellowish grains included Gram staining, which showed extensively branched Gram-positive hyphae less than 1 mm in diameter, allowing to make a diagnosis of Actinomycetoma. Since Actinomycetoma is sensitive to drug treatment, the patient was given trimethoprim-sulfamethoxazole and amikacin twice daily for 45 days. After six months of chemotherapy, the patient's general condition improved, the swelling is slightly diminished and grain extrusion has ceased. The patient has been able to resume ambulation with normal footwear. Given the absence of liver and kidney functional alterations, the patient is scheduled to continue pharmacological treatment with trimethoprim-sulfamethoxazole.

Immunohistochemistry of the enthesis organ of the human Achilles tendon.

BACKGROUND: The insertional region of the Achilles tendon includes: the fibrocartilage of the enthesis at the tendon-bone junction, the sesamoid fibrocartilage in the deep surface of the tendon, and the periosteal fibrocartilage covering the superior tuberosity of the calcaneus. The mechanism by which compressive stress and low oxygen concentration modulate the phenotypical expression of cartilaginous cells in mesenchymal tissue is still unknown. Tenascin-C isoform, with its anti-adhesive properties, has been hypothesized to have a role in cellular adaptation to compression. The purpose of this study was to define the immunohistochemical localization of tenascin-C in the enthesis organ of the Achilles insertion in man. METHODS: Five specimens of Achilles tendon and its insertion were obtained from adult patients during below-knee amputation surgery. To determine the histochemistry, for light microscopy, specimens were stained with hematoxylin-eosin, safranin-O, Verhoeff, alcian blue methods. For immunohistochemistry, the following antibodies were used: anti-S-100 protein; anti-chondroitin sulfate; anti-types I and II collagen, anti-type IV collagen, anti-type X collagen, and anti-tenascin-C. RESULTS: The enthesis, sesamoid, and periosteal fibrocartilages have been defined by a separate region of immunohistochemical labeling for S-100 antibody and type II collagen and chondroitin-sulfate. The sesamoid and periosteal fibrocartilages stained for tenascin-C, which in cartilaginous areas was closely associated with rounded cells in the extracellular matrix. CONCLUSION: By showing a relationship between chondrocyte-like cells and immunolabeling for tenascin-C in periosteal and sesamoid fibrocartilage, the present data suggest a role in the dynamic equilibrium in the formation of fibrocartilaginous foci in tendon areas exposed to compressive stress. CLINICAL RELEVANCE: The data support the surgical practice of the resection of the diseased tendinous portion in case of chronic Achilles tendinitis. The decompression removed the enthesis organ that in an inflammatory environment could be altered and would not contribute to the distribution of the tensive load. After the decompression, it was hypothesized that in tendon areas exposed to compressive stress there was restoration of the fibrocartilaginous foci that constitute the enthesis organ.

Elbow heterotopic ossification in head-trauma patients: diagnosis and treatment.

Heterotopic ossification is a disorder characterized histologically and radiographically by normal bone formation in soft tissues that normally have no ossification properties. In severe head-trauma patients, a high incidence of heterotopic ossification occurs. The diagnosis of this pathology in these patients often is difficult for residual neurological damage. The etiology of heterotopic ossification following head trauma is unknown. Similarities have been found between heterotopic ossification and myositis ossificans, a hereditary autosomal dominant disease.